Health inspection·July 31, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to conduct comprehensive assessment and implement wound care management for one (R1) of three residents reviewed for skin alteration. This deficiency resulted in R1's abrasion on the left great toe deteriorated to necrosis, gangrene, infection of left foot, and needs amputation. Findings include:R1 is an [AGE] year-old, male, admitted in the facility on 07/03/25 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Type 2 Diabetes Mellitus without Complications; Pain in Right Foot; Pain in Left Foot; and Multiple Subsegmental Thrombotic Pulmonary Emboli without Acute Cor Pulmonale. MDS (Minimum Data Set) dated 07/10/25 recorded R1's BIMS (Brief Interview for Mental Status) score is 0, which means severe cognitive impairment.R1's progress notes documented:07/03/25: received R1 in stable condition. The left great toe had a D/I (debridement and irrigation) done, has order for Silvadene 1% topical cream with dressing daily, and to follow up with Podiatry.07/04/25 - Skin/Wound note: abrasion noted to the left great toe with some discoloration. R1's POS (Physician Order Sheet) dated 07/03/25 recorded: Silver Sulfadiazine external cream 1% (Silver Sulfadiazine) apply to left great toe, nail area topically one time a day for dermatology.Wound assessment detail report dated 07/04/25 documented R1's Left toe as abrasion present upon admission, measuring 4 cm (centimeters) x 2 cm x 0.10 cm with light amount of blood exudate.On 07/28/25 at 11:28AM, V5 (Wound Care Coordinator) was asked regarding R1's abrasion on the left great toe. V5 stated, When he (R1) was admitted , he was assessed to have abrasion on the left great toe. Initially he came from the hospital with orders of Silvadene cream and we were applying it. Then the podiatrist (V10) saw him two to three days prior to discharge and changed the order to betadine and dry dressing. R1's POS documented the following:07/09/25: Cleanse left great toe with normal saline, apply betadine-soaked gauze and a dry dressing, every 8 hours as needed for if soiled or dislodged.07/09/25: Cleanse left great toe with normal saline, apply betadine-soaked gauze and a dry dressing, every day shift every Tue, Thu, Sat to promote skin healing. Medical Practitioner note dated 07/12/25, authored by V10 (Podiatrist) recorded the following:Date of service 07/09/25Physical Exam: Integument - necrosis of left hallux noted. R1 was seen by V10 on 07/09/25, noted necrosis of the left hallux. However, wound assessment details reports dated 07/11/25 still documented his (R1) left toe as abrasion, measuring 4 cm x 2 cm x 0.10 cm, with light amount of bloody exudate.On 07/28/25 at 12:05PM, V6 (Licensed Practical Nurse/Treatment Nurse) was asked regarding R1's wound on the left great toe. V6 verbalized, Upon admission, he had an abrasion to his left great toe with some discoloration. He had admitting orders from hospital for Silvadene. When I did the assessment, he had the abrasion to his left toe with discoloration. The wound was bluish dark in color, had some discharges under nail, the nail was still there, there was pain but no swelling. R1's medical practitioner progress note dated 07/10/25 recorded:Plan: Cellulitis and necrosis of left great toe; wound care on consult with wound care orders, in ongoing Residents Affected - Few Page 1 of 2 146053 146053 07/31/2025 Aliya of Palos Park 12220 South Will Cook Road Palos Park, IL 60464

F 0684 Level of Harm - Actual harm Residents Affected - Few antibiotics. On 07/29/25 at 11:56AM, V10 was interviewed regarding R1. V10 replied I've seen him last 07/09/25 because of wound care toenail debridement. There was gangrene, necrosis on his left hallux (great toe). Gangrene could be dry or wet. He has dry gangrene, with dead tissues, necrotic. It was treated with betadine and dry dressing. When I talked to V5, she said she is already taking care of it and wound care is seeing the resident (R1). But I still made a note, I wrote it in a prescription pad regarding referral to wound care. I wrote there to please evaluate and treat wound care consult. I want to make sure wound care team is following the resident (R1). Gangrene can get worse in a few days. Gangrene is from poor blood supply. If there is no blood supply, the wound cannot heal.On 07/29/25 at 10:40 AM, a follow - up interview with V5 was conducted regarding R1's wound care consult. V5 mentioned, R1 was not referred to wound care because it was only an abrasion. Wound Doctor does not see skin tear or abrasions.R1's POS dated 07/04/25 documented: May be seen by Wound Care Specialist.Progress notes dated 07/13/25 indicated that R1 was sent to the hospital due to wound on left toe, per family's request.Progress notes dated 07/14/25 documented R1 was admitted in the hospital with diagnosis of cellulitis of great left toe.Hospital records dated 07/13/25 documented the following:1. Infectious Disease Consultation 07/14/25Impression: Left hallux gangrene, diabetic infection of left foot.Active problems: Paronychia of great toe; necrotic toes; sepsisSuspect (R1) will need amputation. Wet gangrene without surrounding cellulitis.2. Xray (XR) of toe, 1st great left, 07/13/25: Narrative: XR toe 1st great left indication: Left toe infection3. History and Physical 07/14/25Date patient seen: 07/14/25Assessment and plan: Left great 1st toe necrosis; diabetic infection of left footPresented for left great toe evaluation, found to have black necrotic toe suspicious for diabetic foot wound infection with superimposed element of ischemia due to PAD (Peripheral Artery Disease). It is unclear when left great toe changes started, rest of HPI (history of present illness) limited due to patient dementia.Physical examination:Skin - necrotic and black left great toe. R1's care plan documented:1. Potential and is at risk for alteration in skin integrity: Abrasion to the left toe.Interventions:Monitor for signs and symptoms of infectionTreatment orders in place.Notify MD (Medical Doctor) and responsible party of any significant changes.2. admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including direct therapy services, skilled nursing care, management and evaluation of the patient care plan, observation and assessment of the patient's condition.Interventions:Provide skin treatments per MD order. Follow plan of care for skin management. On 07/30/25 at 11:59AM, V3 (Assistant Director of Nursing) was also interviewed regarding R1. V3 verbalized, He has wound to his left toe. The left toe is dark in color. Wound care nurse does the treatment, Silvadene cream. When wound is necrotic, wound care MD has to see it. Facility's policy titled Skin Care Prevention dated 1/2025 stated in part but not limited to the following:General: All residents will receive appropriate care to decrease the risk of skin breakdown. 146053 Page 2 of 2